What was once called “bedside manner” and considered a matter of etiquette and personal style has now been the subject of a large number of empirical studies. The results of these studies suggest that the interview is integral to the process and outcomes of medical care.
|“Tell me more about how you spend your days.”|
|Although she complains of her loneliness and long days in front of the TV, Mrs. Klein refuses to participate in activities at the community senior center. “I’m not playing bingo with a bunch of old ladies,” she tells her doctor when he suggests she get out more. “You’ve mentioned how much you love to garden,” her doctor says. “The center has a garden club with a master gardener. One of my other patients says she loves it.” “I don’t want to hang around old people who have nothing better to do than compare health problems,” she says. “Why not give it a try?” her doctor asks. “You might find the members are pretty active gardeners.” Six months later, when she sees the doctor again, Mrs. Klein thanks him. She has joined the garden club and reports that the members all have green thumbs as well as being quite lively conversationalists. Better still, Mrs. Klein’s depressive symptoms seem improved.|
Effective communication has practical benefits. It can:
- help prevent medical errors
- strengthen the patient-provider relationship
- make the most of limited interaction time
- lead to improved health outcomes
This chapter provides tips on how to communicate with older patients in ways that are respectful and informative.
Use Proper Form of Address
Establish respect right away by using formal language. As one patient said, “Don’t call me Edna, and I won’t call you Sonny.” You might ask your patient about preferred forms of address and how she or he would like to address you. Use Mr., Mrs., Ms., and so on. Avoid using familiar terms, like “dear” and “hon,” which tend to sound patronizing. Be sure to talk to your staff about the importance of being respectful to all of your patients, especially those who are older and perhaps used to more formal terms of address.
|For more information on active listening, contact:|
American Academy on Communication in Healthcare
16020 Swingley Ridge Road, Suite 30
Chesterfield, MO 63017
This professional organization aims to improve physician-patient relationships and offers courses and publications on medical encounters and interviews.
Macy Initiative in Health Communication
Division of Primary Care
NYU School of Medicine
550 First Avenue
New York, NY 10016
This initiative was a collaborative effort of three medical schools to identify and define critical communication skills needed by physicians. It developed competency-based curricula for medical students.
New England Research Institutes (NERI)
9 Galen Street
Watertown, MA 02472
NERI has designed a CME-accredited CD-ROM, Communicating With Older Patients, educating physicians on communication strategies to practice with older patients.
Make Older Patients Comfortable
Ask staff to make sure patients have a comfortable seat in the waiting room and help with filling out forms if necessary. Be aware that older patients may need to be escorted to and from exam rooms, offices, and the waiting area. Staff should check on them often if they have to wait long in the exam room.
Take a Few Moments to Establish Rapport
Introduce yourself clearly. Show from the start that you accept the patient and want to hear his or her concerns. If you are a consultant in a hospital setting, remember to explain your role or refresh the patient’s memory of it.
In the exam room, greet everyone and apologize for any delays. With new patients, try a few comments to promote rapport: “Are you from this area?” or “Do you have family nearby?” With established patients, friendly questions about their families or activities can relieve stress.
Try Not to Rush
Avoid hurrying older patients. Time spent discussing concerns will allow you to gather important information and may lead to improved cooperation and treatment adherence.
Feeling rushed leads people to believe that they are not being heard or understood. Be aware of the patient’s own tendency to minimize complaints or to worry that he or she is taking too much of your time.
One study found that doctors, on average, interrupt patients within the first 18 seconds of the initial interview. Once interrupted, a patient is less likely to reveal all of his or her concerns. This means finding out what you need to know may require another visit or some follow-up phone calls.
Older people may have trouble following rapid-fire questioning or torrents of information. By speaking more slowly, you will give them time to process what is being asked or said. If you tend to speak quickly, especially if your accent is different from what your patients are used to hearing, try to slow down. This gives them time to take in and better understand what you are saying.
Use Active Listening Skills
Face the patient, maintain eye contact, and when he or she is talking, use frequent, brief responses, such as “okay,” “I see,” and “uh-huh.” Active listening keeps the discussion focused and lets patients know you understand their concerns.
|For more information on low literacy, contact:|
Partnership for Clear Health Communication
National Patient Safety Foundation
132 MASS MoCA Way
North Adams, MA 01247
This national coalition addresses issues related to low health literacy and its effect on outcomes. Its “Ask Me 3” campaign has materials for physicians’ offices, including patient handouts, to promote good communication.
Watch for opportunities to respond to patients’ emotions, using phrases such as “That sounds difficult” or “I’m sorry you’re facing this problem; I think we can work on it together.” Studies show that empathy can be learned and practiced and that it adds less than a minute to the patient interview. It also has rewards in terms of patient satisfaction, understanding, and adherence to treatment.
Try not to assume that patients know medical terminology or a lot about their disease. Introduce necessary information by first asking patients what they know about their condition and building on that. Although some terms seem commonplace—MRIs, CAT scans, stress tests, and so on—some older patients may be unfamiliar with what each test really is. Check often to be sure that your patient understands what you are saying. You may want to spell or write down diagnoses or important terms to remember.
Reduce Barriers to Communication
Older adults often have sensory impairments that can affect communication. Vision and hearing problems need to be treated and accounted for in communication. Ask older patients when they last had vision and hearing exams.
Compensating for Hearing Deficits
Age-related hearing loss is common. About one-third of people between the ages of 65 and 75, and as many as half of those over the age of 75, have a hearing loss. Here are a few tips to make it easier to communicate with a person who has lost some hearing:
Make sure your patient can hear you. Ask if the patient has a working hearing aid. Look at the auditory canal for the presence of excess earwax.
Talk slowly and clearly in a normal tone. Shouting or speaking in a raised voice actually distorts language sounds and can give the impression of anger.
Avoid using a high-pitched voice; it is hard to hear.
Face the person directly, at eye level, so that he or she can lip-read or pick up visual clues.
Keep your hands away from your face while talking, as this can hinder lip-reading ability.
Be aware that background noises, such as whirring computers and office equipment, can mask what is being said.
If your patient has difficulty with letters and numbers, give a context for them. For instance, say, “‘m’ as in Mary, ‘two’ as in twins, or ‘b’ as in boy.” Say each number separately, (e.g., “five, six” instead of “fifty-six”). Be especially careful with letters that sound alike (e.g., m and n, and b, c, d, e, t, and v).
Keep a note pad handy so you can write what you are saying. Write out diagnoses and other important terms.
Tell your patient when you are changing the subject. Give clues such as pausing briefly, speaking a bit more loudly, gesturing toward what will be discussed, gently touching the patient, or asking a question.
Compensating for Visual Deficits
Visual disorders become more common as people age. Here are some things you can do to help manage the difficulties caused by visual deficits:
Make sure there is adequate lighting, including sufficient light on your face. Try to minimize glare.
Check that your patient has brought and is wearing eyeglasses, if needed.
Make sure that handwritten instructions are clear.
When using printed materials, make sure the type is large enough and the typeface is easy to read.
If your patient has trouble reading, consider alternatives such as tape recording instructions, providing large pictures or diagrams, or using aids such as specially configured pillboxes.
Be Careful About Language
Some words may have different meanings to older patients than to you or your peers. For example, the word “dementia” may connote insanity, and the word “cancer” may be considered a death sentence. Although you cannot anticipate every generational difference in language use, being aware of the possibility may help you to communicate more clearly. Use simple, common language and ask if clarification is needed. Offer to repeat or reword the information: “I know this is complex; I’ll do my best to explain, but let me know if you have any questions or just want me to go over it again.”
Low literacy or inability to read also may be a problem. Reading materials written at an easy reading level may help.
Conclude the visit by making sure the patient understands:
- what the main health issue is
- what he or she needs to do about it
- why it is important to do it
One way to do this is the “teach-back method”—ask patients to say what they understand from the visit. Also, ask if there is anything that might keep the patient from carrying out the treatment plan.
- Address the patient by last name, using the title the patient prefers (Mr., Ms., Mrs., etc.).
- Begin the interview with a few friendly questions not directly related to health.
- Don’t rush, and try not to interrupt; speak slowly and give older patients a few extra minutes to talk about their concerns.
- Use active listening skills.
- Avoid jargon, use common language, and ask if clarification is needed, such as writing something down.
- Ask the patient to say what he or she understands about the problem and what needs to be done.
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